Substance dependence is defined by physiologic and behavioral symptoms, and substance abuse is described in terms of adverse social consequences of substance use. Dependence involves physiologic processes whereas abuse reflects a complex interaction between the individual, the abused substance, and society.

Diagnostic criteria for substance use disorders allow clinicians to:

plan treatment and monitor progress

provide patients access to health insurance coverage.

Following the mnemonic DRiNK TWO 6 PACK can help you determine if your patient’s symptoms meet diagnostic criteria for substance abuse or substance dependence, which then allows you develop an appropriate treatment plan. The mnemonic suggests alcohol abuse and dependence, but it can be applied to any substance.

Substance abuse

DSM-IV-TR1 defines substance abuse as a maladaptive pattern of use leading to clinically significant impairment or distress as evidenced by ≥1 of 4 symptom criteria within a 12-month period. The mnemonic DRiNK aids recall of the 4 symptoms:

Dangerously driving a vehicle or machine when impaired by substances

Ri: Role failure in home, school, or work because of recurrent substance use

No respect for the law, leading to legal problems

Keeps using a substance despite persistent or recurrent social or interpersonal problems.

Finally, the patient must not have met criteria for substance dependence. Although a substance abuse diagnosis is more likely in individuals who recently started using the substance,2 some individuals can have substance-related adverse social consequences for a long time without developing dependence.

Substance dependence

Physiologic dependence is development of tolerance leading to withdrawal symptoms. According to DSM-IV-TR, substance dependence is a maladaptive pattern of substance use leading to clinically significant impairment or distress identified by ≥3 of the 7 symptoms at any time in the same 12-month period. These symptoms can be recalled with the mnemonic TWO 6 PACK:

Tolerance

Withdrawal

Occupational, social, or recreational activities given up or reduced

6

Persistent desire or unsuccessful efforts to cut down or control substance use

Amount of use is excessive

Continues substance use despite having persistent or recurrent physical or psychological problems

Keeps spending a lot of time in search, use, or recovery from the substance.

An early refill request for psychostimulants for your college-age patient

﻿Mr. R, age 18, who has been taking amphetamine/dextroamphetamine, 10 mg/d, twice a day, for attention-deficit/hyperactivity disorder since he was age 10, comes to see you shortly after beginning college asking to refill earlier than usual. He says his symptoms are worse since beginning college and he is finding it difficult to focus in class and keep up with the heavy course work. He says he has been taking an extra 10 mg when he “needs the extra boost.” He asks for an early refill and increased dosage. How do you proceed?

Switch to an extended release formulation and increase the dosage to 30 mg/d

Switch to lisdexamfetamine, 30 mg/d

Prescribe amphetamine/dextroamphetamine, 10 mg, on an as-needed basis

Tell Mr. R to take his current prescription as prescribed and discuss the dangers of stimulant abuse. Reassess his symptoms at the next visit.